Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 41: What are the findings in ultrasound suggestive of an incompetent internal os?

A. Cervical length, external os, internal os
B. Cervical length, funneling of amniotic sac
C. External os, internal os
D. Cervical length, funneling of amniotic sac, AP length of cervix (Correct Answer)

Explanation: **Explanation:** Cervical insufficiency (incompetent internal os) is a clinical diagnosis characterized by the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions. Ultrasound, specifically **Transvaginal Sonography (TVS)**, is the gold standard for objective assessment. **Why Option D is Correct:** The diagnosis relies on a triad of morphologic changes: 1. **Cervical Length:** A length **<25 mm** before 24 weeks is the most sensitive predictor. 2. **Funneling:** This represents the protrusion of the amniotic membranes into the internal os. It follows a predictable sequence described by the mnemonic **TRUST** (T → Y → V → U shape), where 'U' shape indicates the most advanced stage. 3. **AP (Anteroposterior) Diameter:** An increase in the width of the cervical canal (internal os diameter >15 mm) is a significant marker of structural weakness. **Analysis of Incorrect Options:** * **Options A, B, and C:** These are incomplete. While cervical length and funneling are critical, they omit the AP diameter/width of the internal os, which is a standard parameter in the sonographic "cervical score." The **external os** (mentioned in A and C) is generally not a reliable indicator of early insufficiency as it often remains closed until the final stages of cervical shortening. **NEET-PG High-Yield Facts:** * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS). * **Best Time for Screening:** 16–24 weeks of gestation. * **The "Stress Test":** Applying fundal pressure or asking the patient to cough during ultrasound can elicit "dynamic" funneling not seen at rest. * **Management:** McDonald’s or Shirodkar’s Cerclage, typically performed between **12–14 weeks** for prophylactic cases.

Question 42: Which of the following is NOT implicated in congenital transmission?

A. Hepatitis A (Correct Answer)
B. Toxoplasmosis
C. Herpes
D. Syphilis

Explanation: **Explanation:** The core concept tested here is the **TORCH complex** and other pathogens capable of vertical transmission (crossing the placenta or infecting the fetus during birth). **1. Why Hepatitis A is the Correct Answer:** Hepatitis A virus (HAV) is transmitted via the **fecal-oral route**. It is an acute, self-limiting infection that does not cause a chronic carrier state or viremia significant enough to cross the placenta. Therefore, it is **not** implicated in congenital transmission or fetal malformations. While neonatal infection can theoretically occur if the mother has an active infection during delivery (through fecal contamination), it does not cause "congenital" infection or the syndrome associated with intrauterine transmission. **2. Why the other options are incorrect:** * **Toxoplasmosis:** A classic member of the TORCH group. It crosses the placenta (especially in the third trimester) and can cause the classic triad of chorioretinitis, hydrocephalus, and intracranial calcifications. * **Herpes (HSV):** Transmission usually occurs during delivery through an infected birth canal (vertical transmission). It can cause devastating neonatal encephalitis, skin-eye-mouth (SEM) lesions, or disseminated disease. * **Syphilis:** Caused by *Treponema pallidum*, it readily crosses the placenta after 16–20 weeks of gestation. It leads to "Congenital Syphilis," characterized by features like Hutchinson’s teeth, saddle nose, and saber shins. **Clinical Pearls for NEET-PG:** * **Hepatitis B, C, and E** can be transmitted vertically, but **Hepatitis A and E** are primarily fecal-oral. Note: Hepatitis E in pregnancy is high-yield due to the high risk of **fulminant hepatic failure** and maternal mortality. * **Most common** infection transmitted in utero is **CMV**. * **Most common** cause of congenital sensorineural deafness is **CMV**. * **Parvovirus B19** is a common "Other" in TORCH, known for causing **Hydrops Fetalis** due to fetal anemia.

Question 43: Which of the following is NOT a criterion for expectant management in pre-eclampsia?

A. Platelet count < 100,000/ml
B. Blood pressure > 140/90 mm Hg (Correct Answer)
C. Urine output < 400 ml/day
D. Persistent headache

Explanation: In pre-eclampsia, the decision between expectant management and delivery depends on the severity of the disease and the presence of **"Features of Severity."** **Explanation of the Correct Answer:** **Option B (BP > 140/90 mm Hg)** is the correct answer because it is the **baseline definition** of pre-eclampsia, not a contraindication to expectant management. Expectant management is typically considered in stable patients with "Pre-eclampsia without severe features" between 24 to 34 weeks of gestation. A blood pressure of 140/90 mm Hg is mild; only when BP reaches **≥ 160/110 mm Hg** (Severe Hypertension) does it become a criterion to reconsider expectant management or initiate urgent antihypertensive therapy. **Analysis of Incorrect Options (Criteria for Termination/Severe Features):** Expectant management is contraindicated (or must be terminated) if any of the following severe features develop, as they indicate end-organ damage: * **Option A (Platelets < 100,000/ml):** Indicates thrombocytopenia, a sign of HELLP syndrome or worsening coagulopathy. * **Option C (Urine output < 400 ml/day):** Indicates oliguria and impending renal failure. * **Option D (Persistent headache):** Represents cerebral symptoms (neurological involvement) and is a precursor to eclampsia (seizures). **High-Yield NEET-PG Pearls:** * **Definitive Treatment:** The only definitive cure for pre-eclampsia is the delivery of the placenta. * **Expectant Management Goal:** To improve fetal maturity (administer steroids) without compromising maternal safety. * **Absolute Indications for Delivery:** Eclampsia, Abruptio Placentae, Pulmonary edema, DIC, and Non-reassuring fetal heart rate. * **Magnesium Sulfate ($MgSO_4$):** The drug of choice for seizure prophylaxis in severe pre-eclampsia.

Question 44: Which of the following is NOT an absolute maternal indication for termination of pregnancy?

A. Parous woman with grade III and IV cardiac lesions (Correct Answer)
B. Eisenmenger's syndrome
C. Primary pulmonary hypertension
D. Pulmonary veno-occlusive disease

Explanation: In maternal-fetal medicine, the decision to terminate a pregnancy is based on the risk of maternal mortality. Certain cardiac conditions carry such a high risk (up to 30-50%) that pregnancy is strictly contraindicated. **Explanation of the Correct Answer:** **Option A (Parous woman with grade III and IV cardiac lesions)** is the correct answer because it is a **relative**, not absolute, indication for termination. While NYHA Class III and IV cardiac diseases signify significant functional limitation and high risk, they are often manageable with intensive care, bed rest, and optimized medical therapy. The term "parous" implies the patient has successfully navigated a previous pregnancy, though the current risk remains high. Termination is offered, but it is not a mandatory medical absolute if the patient chooses to proceed under high-risk surveillance. **Explanation of Incorrect Options (Absolute Indications):** The following conditions carry a prohibitively high risk of death (WHO Class IV risk) and are absolute indications for termination: * **Eisenmenger’s Syndrome (Option B):** Reversal of shunt due to pulmonary hypertension leads to severe hypoxemia; mortality exceeds 50%. * **Primary Pulmonary Hypertension (Option C):** The fixed pulmonary vascular resistance cannot accommodate the increased cardiac output of pregnancy, leading to right heart failure. * **Pulmonary Veno-occlusive Disease (Option D):** Similar to pulmonary hypertension, this condition carries an extremely high risk of sudden maternal collapse. **NEET-PG High-Yield Pearls:** * **WHO Class IV Cardiac Conditions (Absolute Contraindications):** Eisenmenger syndrome, Severe Pulmonary Hypertension, Severe Systemic Ventricular Dysfunction (EF <30%), Previous Peripartum Cardiomyopathy with residual impairment, and Severe Aortic Stenosis/Coarctation. * **Marfan Syndrome:** Termination is indicated if the aortic root diameter is **>40 mm**. * **Mitral Stenosis:** It is the most common cardiac lesion in pregnancy in India; while dangerous, it is usually managed medically or via valvotomy rather than mandatory termination.

Question 45: Metcalfe's Criteria is used for:

A. Assessing risk of maternal mortality in pregnancy
B. Grading congenital valvular heart diseases in pregnancy
C. Findings suggestive of heart disease in pregnancy (Correct Answer)
D. Classifying various cardiomyopathies

Explanation: ### Explanation **Correct Answer: C. Findings suggestive of heart disease in pregnancy** **Understanding Metcalfe’s Criteria** During a normal pregnancy, physiological changes—such as increased cardiac output, tachycardia, and peripheral edema—often mimic symptoms of organic heart disease. To differentiate between normal physiological adaptations and true pathology, **Metcalfe’s Criteria** (also known as Burwell and Metcalfe’s Criteria) are used. According to these criteria, heart disease is suspected if any of the following are present: 1. **Diastolic murmur** (always pathological). 2. **Systolic murmur** of Grade III intensity or higher. 3. **Unequivocal cardiomegaly** on imaging. 4. **Severe arrhythmia** (e.g., atrial fibrillation or flutter). **Analysis of Incorrect Options:** * **Option A:** Maternal mortality risk is typically assessed using the **Modified WHO (mWHO) Classification**, which categorizes cardiac conditions based on the risk of pregnancy-related death. * **Option B:** Grading of valvular diseases is done via echocardiographic parameters (e.g., valve area, pressure gradients) and is not specific to Metcalfe’s criteria. * **Option D:** Cardiomyopathies are classified based on morphology and physiology (e.g., Dilated, Hypertrophic, Restrictive) or timing (e.g., Peripartum Cardiomyopathy). **High-Yield Clinical Pearls for NEET-PG:** * **Most common heart disease in pregnancy (India):** Rheumatic Heart Disease (Mitral Stenosis is the most common lesion). * **Most common heart disease in pregnancy (Developed nations):** Congenital Heart Disease. * **NYHA Classification:** Used to assess the *functional capacity* and severity of symptoms in pregnant patients with known heart disease. * **Danger periods:** The risk of heart failure is highest at **28–32 weeks** (peak blood volume), during **labor**, and immediately **postpartum** (autotransfusion from the uterus).

Question 46: Which of the following does NOT constitute a high-risk pregnancy?

A. Twins
B. A 25-year-old primigravida (Correct Answer)
C. Hydramnios
D. Previous Lower Segment Caesarean Section (LSCS)

Explanation: **Explanation:** A **high-risk pregnancy** is defined as one in which the mother, the fetus, or the newborn is at an increased risk of morbidity or mortality due to conditions preceding or accompanying the pregnancy. **Why Option B is Correct:** A **25-year-old primigravida** represents the ideal biological age for childbearing. In obstetrics, the "safe" age for pregnancy is generally considered between 20 and 30 years. Since there are no associated medical or obstetric complications mentioned, this is considered a **low-risk or "normal" pregnancy.** **Why the other options are High-Risk:** * **Twins (Multiple Pregnancy):** This is high-risk due to increased chances of preterm labor, pre-eclampsia, gestational diabetes, and postpartum hemorrhage (PPH). * **Hydramnios (Polyhydramnios):** Excessive amniotic fluid is associated with maternal diabetes, fetal anomalies (e.g., esophageal atresia), cord prolapse, and placental abruption. * **Previous LSCS:** This constitutes a high-risk case due to the risk of **scar dehiscence or rupture** in subsequent pregnancies, as well as an increased incidence of morbidly adherent placenta (Placenta Accreta Spectrum). **Clinical Pearls for NEET-PG:** * **Elderly Primigravida:** A woman becoming pregnant for the first time at age **≥35 years** is considered high-risk. * **Teenage Pregnancy:** Pregnancy at age **<18-19 years** is high-risk due to increased risks of cephalopelvic disproportion (CPD) and pre-eclampsia. * **Stature:** A maternal height of **<140-145 cm** (short stature) is a high-risk factor for CPD. * **Grand Multipara:** A woman who has had **4 or more** previous viable births is at high risk for malpresentations and atonic PPH.

Question 47: A 24-week pregnancy scan revealed frontal facial fetal defects suggestive of Moebius syndrome. Which of the following could account for the teratogenic effects?

A. Mifepristone
B. Misoprostol (Correct Answer)
C. Dinoprostone
D. Methotrexate

Explanation: **Explanation:** **Misoprostol** is a synthetic prostaglandin E1 (PGE1) analogue. When used in the first trimester for failed medical abortion, it can cause uterine contractions leading to **vascular disruption** in the developing fetus. This vascular insult (specifically involving the subclavian artery or cranial vessels) results in **Moebius Syndrome**, characterized by congenital paralysis of the 6th (abducens) and 7th (facial) cranial nerves, often associated with limb reduction defects and orofacial malformations. **Analysis of Incorrect Options:** * **Mifepristone (A):** An anti-progestogen used for medical abortion. While it terminates pregnancy by blocking progesterone receptors, it is not specifically linked to the vascular disruption sequence seen in Moebius syndrome. * **Dinoprostone (C):** A PGE2 analogue used primarily for cervical ripening and induction of labor at term. It is not typically associated with first-trimester teratogenicity leading to Moebius syndrome. * **Methotrexate (D):** A folate antagonist. Teratogenicity (Fetal Methotrexate Syndrome) typically presents with "cloverleaf skull," craniosynostosis, wide-set eyes, and limb defects, rather than the specific cranial nerve palsies of Moebius syndrome. **NEET-PG High-Yield Pearls:** * **Moebius Syndrome Triad:** Facial paralysis (mask-like facies), impaired lateral eye movement, and limb deformities (e.g., clubfoot). * **Vascular Disruption Sequence:** The same mechanism (Misoprostol) can also cause **Poland Syndrome** (unilateral absence of pectoralis major and syndactyly). * **Safe Use:** Misoprostol is highly effective for PPH prophylaxis and medical abortion, but patients must be counseled on the teratogenic risks if the pregnancy continues.

Question 48: What are the causes of hydramnios?

A. Anencephaly
B. Oesophageal atresia
C. Twins
D. All of the above (Correct Answer)

Explanation: **Explanation:** Hydramnios (Polyhydramnios) is defined as an amniotic fluid index (AFI) > 25 cm or a single deepest pocket (SDP) > 8 cm. It occurs when there is either an **overproduction of fetal urine** or an **impairment in fetal swallowing/absorption** of amniotic fluid. **Why "All of the Above" is Correct:** * **Anencephaly (A):** This is a classic cause of polyhydramnios due to two mechanisms: 1. **Failure of swallowing reflex** because of the absence of the forebrain and neural centers. 2. **Transudation of fluid** from the exposed meninges/exposed plexus. 3. **Lack of Antidiuretic Hormone (ADH)** leading to excessive fetal polyuria. * **Oesophageal Atresia (B):** This represents a mechanical obstruction. Since the fetus cannot swallow the amniotic fluid, it cannot be absorbed by the fetal gastrointestinal tract, leading to fluid accumulation in the amniotic sac. * **Twins (C):** Polyhydramnios is common in multiple gestations, particularly in **Monochorionic Diamniotic (MCDA) twins** as part of **Twin-to-Twin Transfusion Syndrome (TTTS)**. The recipient twin develops polyuria due to hypervolemia, leading to polyhydramnios. **High-Yield NEET-PG Pearls:** * **Most common cause:** Idiopathic (approx. 50-60%). * **Most common maternal cause:** Maternal Diabetes Mellitus (osmotic diuresis in the fetus due to hyperglycemia). * **Congenital anomalies:** Associated with neural tube defects (NTDs), GI obstructions (duodenal atresia - "double bubble" sign), and facial clefts. * **Complications:** Preterm labor, Premature Rupture of Membranes (PROM), Cord prolapse, and Postpartum Hemorrhage (PPH) due to uterine atony. * **Management:** Therapeutic amniocentesis (amniodrainage) or Indomethacin (decreases fetal urine output, but contraindicated after 32 weeks due to risk of premature closure of Ductus Arteriosus).

Question 49: On sonography, a multigravida is found to have oligohydramnios. Which among the following will be associated with this condition?

A. Oesophageal atresia
B. Spina bifida
C. Cholangioma of placenta
D. Renal agenesis (Correct Answer)

Explanation: **Explanation:** **Understanding the Concept:** Amniotic fluid volume is a dynamic balance between production and removal. After 12–14 weeks of gestation, **fetal urine** becomes the primary source of amniotic fluid, while **fetal swallowing** is the major route of its removal. **Why Renal Agenesis is Correct:** In cases of **Renal Agenesis** (Potter’s Sequence), the kidneys fail to develop, leading to a total absence of fetal urine production. Since the primary source of fluid is missing, it results in severe **oligohydramnios** (Amniotic Fluid Index < 5 cm or Single Deepest Pocket < 2 cm). **Analysis of Incorrect Options:** * **Oesophageal Atresia:** This condition prevents the fetus from swallowing amniotic fluid. Since the removal mechanism is blocked while urine production continues, it leads to **polyhydramnios**. * **Spina Bifida:** Open neural tube defects (NTDs) cause **polyhydramnios** due to the transudation of cerebrospinal fluid into the amniotic sac and impaired fetal swallowing. * **Chorioangioma of Placenta:** This is a vascular tumor of the placenta. Large chorioangiomas (>5 cm) act as arteriovenous shunts, leading to high-output cardiac failure in the fetus, increased fetal urine production, and subsequent **polyhydramnios**. **NEET-PG High-Yield Pearls:** * **Most common cause of oligohydramnios:** Premature Rupture of Membranes (PROM). * **Most common fetal anomaly associated with oligohydramnios:** Renal anomalies (e.g., Posterior Urethral Valves, Polycystic Kidney Disease). * **Potter’s Sequence:** Oligohydramnios → Pulmonary hypoplasia, flattened facies, and limb deformities (clubfoot). * **Drug-induced oligohydramnios:** ACE inhibitors and NSAIDs (due to decreased fetal renal perfusion).

Question 50: What is the most common type of anemia in pregnancy?

A. Megaloblastic anemia
B. Microcytic hypochromic anemia (Correct Answer)
C. Microcytic normochromic anemia
D. Normochromic normocytic anemia

Explanation: **Explanation:** **Iron Deficiency Anemia (IDA)** is the most common cause of anemia during pregnancy worldwide, accounting for nearly 75–90% of cases. Morphologically, IDA is characterized as **Microcytic Hypochromic Anemia**. **Why the correct answer is right:** During pregnancy, there is a significant increase in maternal iron requirements to support the expanding red cell mass and the growing fetus/placenta. If iron stores are insufficient to meet this demand, hemoglobin synthesis is impaired. This results in smaller red blood cells (low Mean Corpuscular Volume - **Microcytic**) with reduced hemoglobin concentration (low Mean Corpuscular Hemoglobin Concentration - **Hypochromic**). **Analysis of Incorrect Options:** * **Megaloblastic Anemia (Option A):** Usually caused by Vitamin B12 or Folic acid deficiency. While common in pregnancy, it is the second most common cause after IDA and presents as macrocytic anemia. * **Microcytic Normochromic Anemia (Option C):** This is an uncommon morphological pattern. Microcytosis is almost always accompanied by hypochromia in the context of nutritional deficiencies. * **Normochromic Normocytic Anemia (Option D):** This is the pattern seen in **Physiological Anemia of Pregnancy**, caused by a disproportionate increase in plasma volume (50%) compared to red cell mass (20–30%), leading to hemodilution. However, it is not considered a "pathological" anemia. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Definition:** Anemia in pregnancy is defined as Hb **< 11 g/dL**. * **Gold Standard Investigation:** Serum Ferritin (levels < 15–30 ng/mL indicate depleted iron stores). * **Prophylaxis:** Under the *Anemia Mukt Bharat* guidelines, pregnant women should receive 60 mg elemental iron and 500 µg folic acid daily for 180 days, starting from the second trimester. * **Parenteral Iron:** Indicated if the patient is intolerant to oral iron or presents with severe anemia in late pregnancy (after 30–32 weeks).

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

Practice Questions

Multiple Gestation

Practice Questions

Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

Practice Questions

Prenatal Diagnosis and Genetic Counseling

Practice Questions

Placental Abnormalities

Practice Questions

Preterm Labor and Delivery

Practice Questions

Management of Medical Disorders in Pregnancy

Practice Questions

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